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The Management of Hypertension In Hemodialysis Patients

The Management of Hypertension In Hemodialysis Patients. Dr. Abdulkareem Alsuwaida Associate Professor King Saud University. Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah.

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The Management of Hypertension In Hemodialysis Patients

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  1. The Management of Hypertension In Hemodialysis Patients Dr. Abdulkareem Alsuwaida Associate Professor King Saud University Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah

  2. Prevalence of hypertension in chronic HD pts(N=65393, mean age 61 yr, mean duration on HD 8 yr) Iseki et al. Ther Apher Dial 2007;11:183-188

  3. Death Due to Strokes and Heart Disease Stroke Heart 32 16 16 8 8 4 stroke deaths Heart deaths 4 2 2 1 135 <120 125 135 148 168 120 125 148 168 SYSTOLIC BLOOD PRESSURE mm Hg

  4. Unadjusted survival by baseline predialysis systolic BP Stidley et al. J Am Soc Nephrol 2006;17:513-520

  5. “Reverse-epidemiology” • Low BP is a consequence of other disease: • Major CVD • Malnutrition-inflammation-atherosclerosis complex • LVD

  6. Mechanism of HTN • Sodium and volume overload. • Sympathetic nervous system activity • Inappropriate renin secretion. • Alteration in endothelin and nitric oxide. • Erythropoietin therapy. • Hyperparathyroidism. • Other: • Uremic toxins, Nocturnal hypoxemia and sleep disturbances Nephrol Dial Transplant. 2004 May; 19(5):1058-68

  7. Mechanism of HTN • Hypervolemia is the major factor • Positive Sodium balance • Increases intake and decreased excretion • Achieving DW will control 60% of cases of HTN • Assessment of DW Am J Kidney Dis. 1996 Aug; 28(2):257-61

  8. Mechanism of HTN • Renin inappropriately high for ? etiology. • Increase vascular resistance • Increased in sympathetic activity • Originate from kidneys • Uremic metabolites that activate chemoreceptors within the kidney • Increase vascular resistance and systemic BP

  9. When and How to measure the BP in dialysis patients? • Dialysis Unit: During, Before, or After • Home BP • ABPM

  10. When and How to measure the BP in dialysis patients? • Predialysis SBP overestimated mean SBP by an average of 10 mm Hg • Postdialysis SBP underestimated mean SBP by an average of 7 mm Hg • BP reasings over a period of 1 to 2 weeks rather than isolated readings should be used

  11. Home blood pressure monitoring is of greater prognostic value than hemodialysis units recordings Alborzi et al. CJASN 2007;2:1228-1234

  12. When and How to measure the BP in dialysis patients? • Interdialytic ABP monitoring best represent BP in dialysis patients. • Only method that will show diurnal variation • Difficult to repeat, Vascular access • Home BP

  13. Relationship between BP and mortality in dialysis patients Luther JM Kidn Int 2008;73:667-668

  14. Target blood pressure? • Scarcity of evidence • Pre-dialysis BP < 150/90 • ABPM < 140/85 • Avoid drop of SBP greater than 30 mm Hg or post dialysis postural hypotension. • Increase mortality and hospitalization • < 110/60 mm Hg correlates significantly with the risk of death within 5 years • Kidney Int 2007;71: 454–61. • Kidney Int 2004;66:1212–20. • Am J Kidn Dis. 2005;45

  15. ABPM systolic BP and mortality. Agarwal R Hypertension. 2010;55:762-768

  16. Management of Hypertension • Step 1: Lifestyle modifications and control of volume status with lifestyle modifications. • Step 2: Control of volume status with dialysis. • Step 3: Administration of antihypertensive drugs.

  17. Life style modifications • Body weight: • 'obesity paradox‘ • Mainly explained by mal-or undernutrition. • Low salt intake • 1000 to 1500 mg of sodium/day • Exercise

  18. Life style modifications • Tobacco use • 59% more CHF • 68% more PVD • Mortality 37% • Foley et al. Kidney Int 2003; 63: 1462-7.

  19. Life style modifications

  20. Management of Hypertension • Control of volume status • Limit interdialytic weight gain • a 2.5 kg is associated with a significant increase in BP • Achieve dry weight • Frequent dialysis & Longer dialysis time Agarwal R, et al. Hypertension. 2009 Mar; 53(3):500-7.

  21. Dry Weight • Criteria to determining DW: • No marked fall in BP during dialysis. • No hypertension (predialysis BP at the beginning of the week <140/90 mm Hg). • No peripheral edema. • No pulmonary congestion on chest X-ray. • Cardiothoracic ratio ≤50% (≤53% in females).

  22. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Agarwal R, et al. Hypertension. 2009 Mar; 53(3):500-7.

  23. Antihypertensive drugs • 160/95 mmHg immediate before the next dialysis session • Campese VM TA. Hypertension in dialysis patients. 2004. • All classes of antihypertensive can be used in dialysis patients (Except diuretics). • Compelling indications are similar

  24. Treatment of Hypertension • ARBs and ACE are the preferable first line of antihypertensive drugs • Prevent left ventricular hypertrophy Cannella G etal.Am J Kidney Dis. 1997 Nov; 30(5):659-64. Suzuki H et al. Am J Kidney Dis. 2008 Sep; 52(3):501-6.

  25. Pharmacokinetic properties of ACE Inhibitors in ESRD Henrich W. Principles and Practice of Dialysis

  26. Pharmacokinetic properties of ARB’s in ESRD Henrich W. Principles and Practice of Dialysis

  27. Pharmacologic properties of β-blockers in chronic dialysis patients Henrich W. Principles and Practice of Dialysis

  28. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Agarwal R et al NDT 2014 • ESRD with LVH • lisinopril (n = 100) or atenolol (n = 100) each administered three times per week after dialysis. • Results: • Hospitalizations for heart failure were worse in the lisinopril group (IRR 3.13, P = 0.021). • All-cause hospitalizations were higher in the lisinopril group [IRR 1.61 (95% CI 1.18-2.19, P = 0.002)].

  29. Resistant Hypertension • Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes.

  30. Resistant HTN in ESRD • Transdermal clonidine at weekly intervals. • Minoxidil, a potent vasodilator, • used with beta blockers • Spironolactone in Hemodialysis Patients • 25-50 mg post dialysis • Risk of hyperkalemia • Improve EF and Improve BP control • Large studies are done

  31. Resistant Hypertension • The use of non steroidal anti-inflammatory drugs • Renovascular hypertension • Increasing cysts in polysystic kidney disease • Compliance

  32. Resistant HTN in ESRD • Renal sympathetic nerve ablation • Hyperactivation of the sympathetic nervous system • J Clin Hypertens (Greenwich). 2012 Nov;14 • The Future? • Device-Based Therapy for Resistant Hypertension • Baroreflex Activation Therapy • Renal Denervation Therapy

  33. Baroreflex Activation Therapy (BAT)Continuously Modulates the Autonomic Nervous System HR Vasodilation Natriuresis Renin secretion

  34. Anatomical Location of Renal Sympathetic Nerves • Arise from T10-L1 • Follow the renal artery to the kidney • Primarily lie within the adventitia The Journal of Clinical Hypertension. 14, pages 799–801,2012 Circulation. 2002;106:1974–1979

  35. Intradialytic hypertension • 5-15% • Mechanism • Extracellular volume overload • Increased cardiac output • Changes in sodium levels • Activation of the renin–angiotensin–aldosterone system • Overactivity of the sympathetic nervous system • Endothelial cell dysfunction. • Removal of anti HTN during dialysis

  36. Intradialytic Hypertension • The most important treatment is adequate sodium and water removal and reducing sympathetic hyperactivity. • Changing to non-dialyzable antihypertensive medications • Altering the dialysis prescription.

  37. Summary • Sodium excess and extracellular volume expansion is the major factor in the development of hypertension. • Lifestyle modifications is critical. • Control of volume status (Dietary salt and fluid restriction). • Correcting adequately volume expansion with dialysis. • All classes of antihypertensive drugs can be used in dialysis patients

  38. Thank You

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